- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.83 / $2,114.90 / $2,649.91
| Facility | | $2,050.83 | $2,114.90 | $2,649.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.50 / $2,185.36 / $3,008.50
| Professional | | $1,678.50 | $2,185.36 | $3,008.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,677.35 / $4,346.43 / $7,750.82
| Facility | | $3,677.35 | $4,346.43 | $7,750.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.90 / $2,225.15 / $3,593.87
| Professional | | $2,214.90 | $2,225.15 | $3,593.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,141.52
| Facility | | $3,141.52 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $2,995.14 / $3,235.77
| Professional | | $2,293.31 | $2,995.14 | $3,235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.24 / $1,933.40 / $2,968.11
| Professional | | $1,514.24 | $1,933.40 | $2,968.11 |